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Patient Satisfaction Survey — Community Pharmacy
Requested By:
Edward Arabov at
Your Name:
First:
Last:
Your Phone #:
Use the following format (XXX) XXX-XXXX
New or Existing Patient:
New
Existing
Service:
Immunization
Medication Therapy Management
New Prescription
Other (Please Note in Comments)
Point of Care Test
Prescription Refill
Make or Serial # (as applicable):
Date of Service:
(mm/dd/yyyy format)
Pharmacist or Pharmacy Tech Name:
Access, Delivery and Service
Yes
No
N/A
1
Responses to questions, concerns were addressed in a timely manner.
2
Service friendly, prompt and courteous.
3
Satisfied with the time spent with the Pharmacist.
4
Did Pharmacist / Staff request info on other medications currently prescribed.
5
Satisfied with medication counseling / instructions provided by the Pharmacist.
6
Satisfied with the length of time for prescription processing.
7
Received info on Patient Rights and Responsibilities.
8
Satisfied with the service. Would recommend to others.
Comments
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